North Dakota Department of Health School Vaccination Survey

2008-2009 North Dakota School Immunization Requirements (pdf)
School Immunization Survey Instructions (pdf)
2008-2009 School Memo (pdf)

Return to Immunization Homepage

Name of the School
Public or Private School
Grade at School Entry
Grade at Middle School Entry
Revised Report
Institution Authority
Email Address
Person Submitting Report
Institution Authority Phone Number
Person Submitting Phone Number

Student Information
GradeKindGR. 1GR. 2GR. 3GR. 4GR. 5GR. 6GR. 7GR. 8GR. 9GR. 10GR. 11GR. 12
Total Students...
Enrolled:
With no immunization record:
Claiming medical exemption:
Claiming religious exemption:
Claiming philosophical exemption:
Claiming moral exemption:
Claiming history of disease exemption:
 
Vaccination Status Total Students...
Fully immunized with Polio vaccine (IPV or OPV):
Fully immunized with DTP/DTaP/DT vaccine:
Fully immunized with MMR vaccine:
Fully immunized with Hepatitis B vaccine:
Fully immunized with Varicella (Chickenpox) vaccine:
Fully immunized with TD/Tdap:      
Fully immunized with Meningococcal vaccine: